Advance care planning process

Any person can participate in advance care planning, even if they are healthy and otherwise well. However, there are key groups within the general population who may be broadly identified as benefiting from early advance care planning. This includes people of any age who:

• are diagnosed with a life-limiting illness or disability
• have multiple comorbidities and are at risk of deterioration
• have early and/or mild cognitive impairment
• manifest general indicators of frailty
• are living with chronic progressive deterioration of disease
• are approaching the end of their life

Queensland Health has developed a multidisciplinary ACP Quick Guide to support clinicians to identify patients who may benefit from advance care planning.

Proactive assessment of medical and psychosocial factors in order to anticipate the person's needs can ensure appropriate and timely treatment, care and support is provided. This proactive focus optimises opportunities to provide care that is consistent with an individual’s goals, values, beliefs and preferences and can include an assessment of the person’s decision-making capacity.

Initiate discussions with the person, as well as their substitute decision-maker(s), family and friends—where appropriate, and with their consent. Topics that may be covered include:

• the person's wishes, preferences or uncertainties in relation to their current or future treatment and care
• the emotions, beliefs or values that may be influencing the person's preferences and decisions
• the person's diagnosis, prognosis and questions about the goals of care
• family members, friends or other substitute decision-maker(s) that the person would like to be involved in decisions about their care
• resuscitation planning, which involves interventions that may be considered or undertaken in an emergency, such as CPR
• access and/or transition to other services, such as to palliative care or other community care services
• the benefits of advance care planning, such as when it may be helpful to make decisions in advance or appoint someone trusted to make decisions on the person's behalf
• the person's preferred place of care (and how this may affect treatment options available)
• the person's needs for religious, spiritual or other personal support
• wishes in relation to funerals, the handling of their body (including cultural needs), and their beliefs or values about organ or tissue donation.

Plan and identify future health and care needs by involving the person in decision-making to the greatest extent possible. This includes identifying and documenting the goals of care, as well as supporting patients to complete formally document of their preferences.

Advance care planning documents may include any of the following:

• Advance Health Directive—a legal document which allows a person to provide directions about future healthcare, and appoint an attorney for health and personal matters. Advance health directives activate only when a person has impaired capacity.
• Enduring Power of Attorney—a legal document giving another person(s) (substitute decision-maker) the authority to make personal (including healthcare) and/or financial decisions on their behalf when the person has impaired capacity.
• Statement of Choices—focuses on wishes, values and beliefs. It is a form used in some Queensland hospitals, residential aged care facilities and GP clinics to support advance care planning conversations. The Statement of choices can guide decision-making, but cannot be used in the same way as an advance health directive, as it is not a legal document.
• The Acute Resuscitation Plan (ARP) was implemented in Queensland Health facilities in 2009 as a statewide form to replace Not for Resuscitation Orders. The ARP is a medical order signed by the most senior doctor available and is designed to provide clinical direction in the event of acute deterioration. The ARP records resuscitation planning outcomes, following discussion with the patient or their substitute decision-maker (if the patient lacks capacity), and other members of the multidisciplinary team.

Completion of an advance health directive, enduring power of attorney or Statement of Choices by a patient is entirely voluntary.

Coordination of care involves ensuring anything discussed or recorded in the context of advance care planning is implemented at the time a patient needs it and is carried out according to individual preferences. Best practice advance care planning is most appropriately coordinated by a multidisciplinary team of health professionals who address the person’s individual physical, emotional, psychological, social, practical, cultural and spiritual needs.

Advance care planning should be reviewed by the multidisciplinary team regularly to ensure currency, consistency and appropriateness with the person's evolving circumstances, needs, goals and preferences. The iterative nature of advance care planning often means it can take time for people to gather and process information, talk to their substitute decision-maker(s), carers and family members, and carry out relevant actions.